GREENE COUNTY MEDICAL CENTER (JEFFERSON, IA) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	11.1%
Iowa:	14.5%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	19.7%
Iowa:	11.4%

Percent of long-stay residents who lose too much weight

This Nursing Home:	9.1%
State:	6.7%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

Here:	26.7%
State:	39.8%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	2.9%
Iowa:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	3.6%
State:	8.4%

Percent of long-stay residents who have depressive symptoms

Here:	18.9%
State:	7.5%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	1.8%
State:	3.9%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
State:	98.0%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	87.3%
State:	97.7%

Percent of long-stay residents who received an antipsychotic medication

Here:	7.3%
State:	21.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.780
State:	0.684

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.370
State:	0.621

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.140
State:	1.298

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.020
Iowa:	0.037

Number Therapy Hours Per Resident Per Day

Here:	0.020
State:	0.043

Complaint Deficiency

Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Potential for minimal harm
- Scope: Many
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Potential for minimal harm
- Scope: Some
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person
- Harm: Potential for minimal harm
- Scope: Many
Fire-resistant interior walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Did not have a written emergency evacuation plan
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Proper fire barriers, ventilation and signs for the transport of oxygen
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have enough backup water supply for essential areas of the nursing home
- Harm: Potential for minimal harm
- Scope: Many
1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Potential for minimal harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many

Use of Medical Imaging

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Nursing Home:	12.100%
Iowa:	8.069%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.061%
State:	0.138%

Process of Care

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

This Nursing Home:	75.0%
State:	96.9%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

This Nursing Home:	95.0%
Iowa:	97.4%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

Here:	78.0%
Iowa:	93.4%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Nursing Home:	78.0%
State:	94.3%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

This Nursing Home:	97.0%
Iowa:	97.8%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

This Nursing Home:	89.0%
State:	96.3%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

This Nursing Home:	92.0%
State:	98.7%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

Here:	90.0%
Iowa:	96.3%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

Here:	90.0%
Iowa:	97.2%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

Here:	100.0%
Iowa:	99.8%

Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery

This Nursing Home:	78.0%
Iowa:	94.2%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

Here:	100.0%
Iowa:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	13.2%
Iowa:	12.0%

30-Day Mortality Rates from Pneumonia

Here:	12.9%
Iowa:	12.0%

30-Day Readmission Rates from Heart Failure

Here:	24.1%
State:	23.7%

30-Day Readmission Rates from Pneumonia

Here:	17.9%
Iowa:	17.9%

GREENE COUNTY MEDICAL CENTER - JEFFERSON, IA